Reimbursement for Abbott Vascular U.S. Products
VASCULAR
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Here is the key information you need to help ensure patient access to cardiovascular care that requires advanced medical technology. You’ll find:

  • Current coding, coverage and payment information pertaining to the full range of our medical technologies.
  • Visit Medicare Reimbursement Guides for summaries of recent Inpatient Hospital, Outpatient Hospital, and Physician Fee Schedule policy changes.
  • Visit C-Codes for a listing of CMS medical device C-Codes.

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.

For a description of Abbott products related to interventional cardiology and peripheral intervention, please see Products

REIMBURSEMENT QUESTIONS?

Contact the Abbott Vascular Product Reimbursement Hotline at 800 354 9997 or Questions@AskAbbottVascular.com.

ABBOTT PRODUCT C-CODES

Effective January 1, 2005, hospitals are required to use Medicare C-Codes when billing for devices used in the outpatient setting. Requiring the use of C-Codes to identify devices used in conjunction with procedures paid for under OPPS will greatly improve the quality of claims data Medicare uses to establish APC payments in the future. The full list of C-codes can be found on the CMS website.

Medicare has established outpatient coding edits dictating which specific C-Codes should be billed with which CPT procedure code. The list of coding edits is not all-inclusive and Medicare will add edits to the list on a quarterly basis in conjunction with the quarterly Outpatient Coding Editor (OCE) release. Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.

The following is an abbreviated list of C-Codes, relevant to Abbott’s vascular products.

For a list of Abbott’s vascular products and their associated C-Codes, please click here: C-Code listing by product

C-Code Medicare Description of the C-Code
C1725 Catheter, Transluminal, Angioplasty, Non-laser
(May include Guidance, Infusion/Perfusion Capability)
C1760 Closure Device, Vascular (Implantable/Insertable)
C1769 Guide Wire
C1874 Stent, Coated/Covered, With Delivery System
C1875 Stent, Coated/Covered, Without Delivery System
C1876 Stent, Non-coated/Non-covered With Delivery System
C1877 Stent, Non-coated/Non-covered Without Delivery System
C1884* Embolization Protective System
C1885 Catheter, Transluminal Angioplasty, Laser
C1887 Catheter, Guiding (May Include Infusion/Perfusion Capability)

For a description of Abbott interventional cardiology products, please click here: Products

 


*Carotid artery stent implantation is an inpatient only procedure for Medicare coverage. The C-Code is used primarily for internal charging to capture the cost of the embolic protection system.

References: HCPCS Release and Code Sets, 2012 Alpha-Numeric HCPCS Downloads accessed on October 1, 2012 from http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp

MEDICARE REIMBURSEMENT GUIDES

Abbott provides summaries of Medicare hospital and physician policy and reimbursement information.  Please click the links below to download the Medicare Reimbursement Guides.

2017 Inpatient Prospective Payment System (IPPS)

(Effective October 1, 2016 to September 30, 2017)
This guide provides a summary of the Medicare Hospital Inpatient Prospective Payment System (IPPS) Update for Fiscal Year 2017.  It includes information regarding the restructuring of Other Cardiothoracic Procedures and 2017 Hospital Inpatient Reimbursement Rates for select cardiovascular MS-DRGs.

For more detailed information, please refer to the FY 2017 IPPS Final Rule on the CMS website. 

2016 Outpatient Prospective Payment System (OPPS)

(Effective January 1, 2016 to December 31, 2016)
This guide provides a summary of the Medicare Hospital Outpatient Prospective Payment System (OPPS) Update for Calendar Year 2016.  It includes updates to the Comprehensive APC Policy, the Transitional Pass-Through Payment Policy, and 2016 Hospital Outpatient Reimbursement Rates for select cardiovascular APCs.

For more detailed information, please refer to the CY 2016 OPPS Final Rule on the CMS website. 

2016 Physician Fee Schedule (PFS)

(Effective January 1, 2016 to December 31, 2016)
This guide provides a summary of the Medicare Physician Fee Schedule Update for Calendar Year 2016.  It includes information on Medicare Provider Payment Modernization after the repeal of the Sustainable Growth Rate (SGR), new CPT codes for Intravascular Ultrasound, and overall payment changes for peripheral interventions, coronary interventions, and transcatheter mitral valve repair procedures. 

To look up payment information for specific procedure codes, AV recommends the Physician Fee Schedule Search tool on the CMS website. 

For more detailed information, please refer to the CY 2016 PFS Final Rule on the CMS website. 

Providers should consult with their payers regarding appropriate documentation, medical necessity, and coding information consistent with individual payer requirements and policies.

CAROTID ARTERY STENTING

Here you’ll find the information you need related to coding, coverage and reimbursement of carotid artery stenting. Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.


CAROTID ARTERY STENTING CODES

Below you will find general coding information related to carotid artery stenting. Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.

ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes are effective as of October 1, 2015. If you have any questions related to the former ICD-9 or current ICD-10 coding for procedures involving Abbott’s devices, please contact the Reimbursement Hotline at 800 354 9997 or Questions@AskAbbottVascular.com

ICD-10-PCS Procedure Codes

ICD-10-PCS tables below are excerpted from the ICD-10-PCS Code Set.  Please refer to the official ICD-10-PCS Code Set for complete tables.

ICD-10-PCS Procedure Codes
0      Medical and Surgical
3      Upper Arteries
7      Dilation – Expanding an orifice or the lumen of a tubular body part
Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7
H Common Carotid Artery, Right
J Common Carotid Artery, Left
K Internal Carotid Artery, Right
L Internal Carotid Artery, Left
 
3 Percutaneous D Intraluminal Device
 
Z No Qualifier

Note: Carotid artery stenting is covered as an inpatient procedure only.  PTA alone of the carotid artery is not covered by CMS. Coverage is limited to procedures performed using FDA-approved carotid artery stents and FDA-approved or -cleared embolic protection devices. The use of an FDA-approved or cleared embolic protection device is required. If deployment of the embolic protection device is not technically possible, and not performed, then the procedure is not covered by Medicare1.

CPT® Procedure Codes

CPT® Procedure Codes
37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection
37216

Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; without distal embolic protection

37218 Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation

Center for Medicare and Medicaid Services (CMS), Pub 100-3 Medicare National Coverage Determinations, Transmittal 115, March 5, 2010. http://www.cms.gov/transmittals/downloads/R115NCD.pdf

 

Center for Medicare and Medicaid Services (CMS), Pub 100-3 Medicare National Coverage Determinations, Transmittal 115, March 5, 2010.http://www.cms.gov/transmittals/downloads/R115NCD.pdf

References:
Centers for Medicare and Medicaid Services at http://www.cms.gov/
ICD-10 Procedure Coding System (ICD-10-PCS) 2016 Tables and Index, downloaded from http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html on 6/30/2015.
CPT® Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


CAROTID ARTERY STENTING PROCEDURE PAYMENT

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.

Note: Currently, carotid artery stenting is covered and paid only as an inpatient procedure.

Medicare Hospital Inpatient Payment

Medicare hospital inpatient information is effective for the fiscal year (FY) (October 1 through September 30)

MS-DRG1 FY 2017 National Base Payment1
034

Carotid artery stent procedure with major complication or comorbidity

$22,961

035

Carotid artery stent procedure with complication or comorbidity

$13,934

036

Carotid artery stent procedure without complication or comorbidity/major complication or comorbidity

$10,428

Medicare Physician Payment

Medicare Physician Payment is effective for the calendar year (January 1 through December 31)

CPT® CY 2016 National Payment2* 2016 Total Facility RVUs
37215

Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection.

$1,054

29.41

37216

Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; without distal embolic protection.

Medicare non-covered service, no payment

N/A

37218

Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation

$862

24.07

 

*National Facility Rate

1 FY2017 Inpatient Prospective Payment System Final Rule CMS-1655-F; CMS-1664-F; CMS-1632-F2.

2 CY2016 Physician Fee Schedule, Final Rule; Centers for Medicare & Medicaid Services 42 CFR Parts 405, 410, 411, 414, 425, and 495 [CMS-1631-FC].  Accessed November 16, 2015.

References:
Centers for Medicare and Medicaid Services at http://www.cms.gov
CPT® Copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


CAROTID ARTERY STENTING COVERAGE

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.

Medicare (CMS) Coverage

CMS coverage of carotid artery stenting (CAS) began in July 2001 when coverage of CAS was limited to patients enrolled in an IDE trial. Since that time, CMS has published multiple related coverage policies for carotid artery stenting. Policies cover CAS in an IDE investigational trial setting, in a post-approval trial setting, in a post-approval extension trial setting, and for a subset of FDA-approved indications, there is coverage outside of trials. Please view the CMS national coverage determination  for additional information.

Please note: Effective December 9, 2009 Medicare clarified coverage for carotid artery stenting requiring the use of an FDA-approved or cleared embolic protection device. Medicare clarified if deployment of the embolic protection device is not technically possible, and not performed, then the procedure is not covered by Medicare.1

In September 2014, CMS granted approval for Percutaneous Transluminal Angioplasty (PTA) to cover carotid artery stenting through the CREST-2 trial and the CREST-2 Registry.  Please view the CMS national coverage determination for additional information.

CREST-2

(Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial)

CREST-2, sponsored by the National Institute of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health (NIH), is intended to evaluate the best approach for managing asymptomatic patients with high-grade carotid atherosclerotic stenosis. This prospective multi-center randomized controlled trial started enrollment in 2014 and is expected to complete final data collection for primary outcome measure in 2020. CREST-2 site selection and credentialing is managed by a multi-disciplinary committee.  Please visit the NIH StrokeNet web site or the CREST-2 Trial web site for additional information.

CREST-2 Registry (C2R)

The objective of CREST-2 Registry is to promote the rapid initiation and completion of patient enrollment in the CREST-2 trial. Accreditation for Cardiovascular Excellence (ACE) was selected by CMS to accredit C2R clinical sites

National Cardiovascular Data Registry (NCDR) Peripheral Vascular Intervention (PVI) Registry  and Society for Vascular Surgery’s Vascular Quality Initiative (VQI)  are the selected registries to administer C2R data collection. Each C2R participating operator/site is required to have membership for either the NCDR-PVI Registry or the SVS-VQI Registry.

Commercial Coverage Policies / Other Third-Party Payers

Because commercial coverage varies regionally, Abbott recommends that providers verify insurance coverage prior to performing procedures.

 

1Center for Medicare and Medicaid Services (CMS), Pub 100-3 Medicare National Coverage Determinations, Transmittal 115, March 5, 2010. http://www.cms.gov/transmittals/downloads/R115NCD.pdf

References:
Centers for Medicare and Medicaid Services at www.cms.gov


CMS APPROVED FACILITIES FOR CAROTID ARTERY STENTING

Effective March 2005, the Centers for Medicare and Medicaid Services (CMS) expanded coverage of carotid artery stenting (CAS) to patients who were not enrolled in medical device trials (IDE or FDA-required post-approval). With the coverage decision, CMS stated that all facilities who planned to develop a carotid stenting program and treat patients outside of studies would have to meet additional requirements. For detailed information about CMS' coverage policy of carotid stenting procedures, please visit:

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=201&ver=9

These requirements are summarized below:

  • All facilities shall submit an affidavit attesting to meeting specific minimum standards or attesting that they have participated in an FDA-approved carotid stenting trial (IDE or FDA required post-approval study)
  • Facilities will collect data on all carotid stenting procedures
  • Facilities will have a clear credentialing program for interventionalists performing carotid stenting

Click here to view the list of CMS Approved Carotid Stenting Facilities at the CMS website.
 


CAROTID STENTING PRIOR AUTHORIZATION TOOL KIT

Abbott offers this Carotid Stenting Prior Authorization Tool Kit for use by physicians and their offices when seeking prior authorization or submitting claims to plans requiring such pre-procedure approvals. This comprehensive tool kit includes information to assist your office in submitting prior authorization requests to private payers to confirm coverage for patients who may benefit from a carotid artery stent (CAS) procedure. Download the guide and the accompanying forms using the links below.

Abbott recommends seeking prior authorization for all cases except those covered by traditional (fee for service) Medicare. Please note, prior authorization is not required for fee for service Medicare patients.

Providers should consult with their payers regarding appropriate documentation, medical necessity, and coding information consistent with individual payer requirements and policies

Should your office need any additional reimbursement support materials or have any questions pertaining to the prior authorization process for CAS patients, please contact the Abbott Reimbursement Hotline at 1-800-354-9997 or questions@askabbottvascular.com

Click to download Tool Kit Instructions
Download this guide for submitting prior authorization requests for your patients to private payers. It includes instructions on how to use this tool kit and the associated forms and provides a checklist of the key steps necessary to request authorization.

Click to download the FDA CAS Approval Letter
Download a copy of the FDA approval letter for the RX Acculink Carotid Stent System. This letter may be required as part of the submission for CAS authorization.

Click to download the Sample STANDARD RISK Letter of Medical Necessity
Download a sample letter template that provides suggestions to assist in writing a Letter of Medical Necessity or prior authorization request for the Acculink Carotid Artery Stent System with Accunet Embolic Protection for patients with carotid artery disease at standard surgical risk. Physicians should customize the letter based on the patient’s actual medical history and diagnosis, and to be consistent with any specific payer requirements.

Click to download the Sample HIGH RISK Letter of Medical Necessity
Download a sample letter template that provides suggestions to assist in writing a Letter of Medical Necessity or prior authorization request for the Acculink Carotid Artery Stent System with Accunet Embolic Protection for patients with carotid artery disease at high surgical risk. Physicians should customize the letter based on the patient’s actual medical history and diagnosis, and to be consistent with any specific payer requirements

CORONARY INTERVENTIONS

Here you’ll find the information you need related to coding, coverage and reimbursement for coronary interventions. Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.


CORONARY INTERVENTION CODES

Below you will find general coding information related to coronary interventions. Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies

ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes are effective as of October 1, 2015. If you have any questions related to the former ICD-9 or current ICD-10 coding for procedures involving Abbott devices, please contact the Reimbursement Hotline at 800 354 9997 or Questions@AskAbbottVascular.com.

ICD-10-PCS Procedure Codes

ICD-10-PCS tables below are excerpted from the ICD-10-PCS Code Set. Please refer to the official ICD-10-PCS Code Set for complete tables.

ICD-10-PCS Procedure Codes
0      Medical and Surgical
2      Heart and Great Vessels
7      Dilation – Expanding an orifice or the lumen of a tubular body part
Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7
0 Coronary Artery, One Site
1 Coronary Artery, Two Sites
2 Coronary Artery, Three Sites
3 Coronary Artery, Four or More
   Sites
3 Percutaneous 4 Intraluminal Device, Drug-
   eluting
D Intraluminal Device
Z No Device
6 Bifurcation
Z No Qualifier

CPT® Procedure Codes/HCPCS Codes

CPT® Codes
92920 Percutaneous transluminal coronary angioplasty; single major coronary artery or branch
92921 Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
92924 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or branch
92925 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
92928 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch
92929 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
92933 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch
92934 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
92937 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel
92938 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure)
92941 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel
 
92943 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel
92944 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)

 

Note: Six of the foregoing codes are separately reportable (92921, 92925, 92929, 92934, 92938, and 92944), when performed, but for payment purposes are bundled into the code immediately preceding each of them in the coding system shown above. Also refer to the table in the Coronary Payment section below.

DES Outpatient Hospital HCPCS Codes

The following HCPCS codes are used for billing hospital DES outpatient services only. 

HCPCS Codes
C9600 Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch
C9601 Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure
C9602 Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch
C9603 Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)
C9604 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel
C9605 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure)
C9606 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel
C9607 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel
C9608 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)

Vessel Closure

The following code has been assigned to occlusive devices by CMS: G0269

G0269 is defined as: placement of an occlusive device in either a venous or arterial access site, post-surgical or interventional procedure. Code G0269 should be used on Medicare claims to record the placement of the vasoseal and for other payers as directed.

 

References:

Centers for Medicare and Medicaid Services at www.cms.gov
ICD-10 Procedure Coding System (ICD-10-PCS) 2016 Tables and Index, downloaded from http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html on 6/30/2015.

CPT® is a trademark of the American Medical Association.

Current Procedure Terminology (CPT®) is copyright 2014. American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

American Medical Association. CPT® 2014. Professional Edition. Chicago, IL.


PAYMENT FOR CORONARY INTERVENTIONS

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.  

Medicare Hospital Inpatient Payment

Medicare hospital inpatient payment is effective for the fiscal year (FY) (October 1 through September 30)

MS-DRG

FY 2017 National 
Base Payment1
246

Percutaneous cardiovascular procedure with drug-eluting stent with major complication or comorbidity or 4+ vessels/stents

$19,396
247

Percutaneous cardiovascular procedure with drug-eluting stent without major complication or comorbidity

$12,658
248

Percutaneous cardiovascular procedure with non-drug-eluting stent with major complication or comorbidity or 4+ vessels/stents

$18,156
249

Percutaneous cardiovascular procedure with non-drug-eluting stent without major complication or comorbidity

$11,544
250

Percutaneous cardiovascular procedure without coronary artery stent or acute myocardial infarction (AMI) with major complication or comorbidity

$15,683
251

Percutaneous cardiovascular procedure without coronary artery stent or acute myocardial infarction (AMI) without major complication or comorbidity

$10,059

Medicare Hospital Outpatient Payment

Medicare hospital outpatient payment is effective for the calendar year (CY) (January 1 through December 31)

APC

CY 2016
National Payment2
5191 Level I Endovascular Procedures^ $4,592
5192 Level II Endovascular Procedures^ $9,542
5193 Level III Endovascular Procedures^ $14,612

^Although these outpatient payments groupings are titled 'Endovascular Procedures' they include coronary interventions as well.  

Medicare Physician Payment

Medicare Physician Payment is effective for the calendar year (CY)  (January 1 through December 31)

CPT®

CY 2016
National Payment*3
2016 Total
Facility RVUs
92920  Percutaneous transluminal coronary angioplasty; single major coronary artery or branch $569 15.87
92921 Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) $0 N/A
92924 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or branch $675 18.84
92925 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) $0 N/A
92928 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch $631 17.62
92929 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) $0 N/A
92933 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch $706 19.71
92934 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) $0 N/A
92937 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel $631 17.60
92938 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure) $0 N/A
92941 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel $708 19.75
92943 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel $707 19.74
92944 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure) $0 N/A

Note: All codes paying $0 are bundled into previous code in table, e.g., 92929 bundled into 92928.

 

* National Facility Rate.

1 FY2017 Inpatient Prospective Payment System Final Rule CMS-1655-F; CMS-1664-F; CMS-1632-F2.
2 CY2016 Outpatient Prospective Payment System Final Rule; 42 CFR Parts 405, 410, 412, 413, 416, and 419 [CMS-1633-FC]; Accessed October 30, 2015.
3 CY2016 Physician Fee Schedule, Final Rule; Centers for Medicare & Medicaid Services 42 CFR Parts 405, 410, 411, 414, 425, and 495 [CMS-1631-FC].  Accessed November 16, 2015.

References
Centers for Medicare and Medicaid Services at www.cms.gov
CPT® Copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


CORONARY INTERVENTIONS COVERAGE

Local Medicare Administrative Contractors (MACs) as well as other third party payers have their own coverage policies for coronary interventions and devices. You should contact your local Medicare Contractor and third party payers for information on their specific coverage policies for interventional cardiology. There is currently no national Medicare coverage decision for coronary interventions. Most local Medicare Contractors, Fiscal Intermediaries and/or Carriers have posted their Local Coverage Determinations (LCD) on interventional cardiology on their websites.

You can find a list of Medicare Administrative Contractors, Fiscal Intermediaries and Carriers at the CMS webpage

 

Absorb GT1 Medicare Hospital and Physician Reimbursement 2016 – Now FDA Approved

PERIPHERAL INTERVENTIONS

Here you’ll find the information you need related to coding, coverage and reimbursement for peripheral interventions. Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.


PERIPHERAL INTERVENTION CODES

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.  

ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes are effective as of October 1, 2015. If you have any questions related to the former ICD-9 or current ICD-10 coding for procedures involving Abbott devices, please contact the Reimbursement Hotline at 800 354 9997 or Questions@AskAbbottVascular.com. In addition to the codes provided below, diagnostic angiography, catheter placement, or radiological supervision and interpretation codes may apply.

ICD-10-PCS Procedure Codes

ICD-10-PCS tables below are excerpted from the ICD-10-PCS Code Set. Please refer to the official ICD-10-PCS Code Set for complete tables.

ICD-10-PCS Procedure Codes
0      Medical and Surgical
4      Lower Arteries
7      Dilation – Expanding an orifice or the lumen of a tubular body part
Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7

9 Renal Artery, Right
A Renal Artery, Left
C Common Iliac Artery, Right
D Common Iliac Artery, Left
E Internal Iliac Artery, Right
F Internal Iliac Artery, Left
H External Iliac Artery, Right
J External Iliac Artery, Left
K Femoral Artery, Right
L Femoral Artery, Left
M Popliteal Artery, Right
N Popliteal Artery, Left
P Anterior Tibial Artery, Right
Q Anterior Tibial Artery, Left
R Posterior Tibial Artery, Right
S Posterior Tibial Artery, Left
T Peroneal Artery, Right
U Peroneal Artery, Left
Y
Lower Artery

3 Percutaneous D Intraluminal Device
Z No Device
Z No Qualifier
ICD-10-PCS Procedure Codes
0      Medical and Surgical
3      Upper Arteries
7      Dilation – Expanding an orifice or the lumen of a tubular body part
Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7
5 Axillary Artery, Right
6
Axillary Artery, Left
7
Brachial Artery, Right
8
Brachial Artery, Left
9
Ulnar Artery, Right
A
Ulnar Artery, Left
B
Radial Artery, Right
C
Radial Artery, Left
Y
Upper Artery
3 Percutaneous Z No Device Z No Qualifier

Peripheral Angioplasty

CPT® Codes
35471 Transluminal balloon angioplasty, percutaneous; Renal or visceral artery
35475 Transluminal balloon angioplasty, percutaneous; Brachiocephalic trunk or branches, each vessel
35476 Transluminal balloon angioplasty, percutaneous; Venous
37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty
37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)
37224 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal angioplasty
37228 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal angioplasty
37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)

Peripheral Stent Placement

CPT® Codes
37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within same vessel, when performed
37223 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within same vessel, when performed (List separately in addition to code for primary procedure)
37226 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
37230 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
37234 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)
37236  Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angiooplasty within the same vessel, when performed; initial artery 
37237  Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure)
37238  Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein 
37239  Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure) 

Vessel Closure

The following code has been assigned to occlusive devices by CMS: G0269

G0269 is defined as: placement of an occlusive device in either a venous or arterial access site, post-surgical or interventional procedure. Code G0269 should be used on Medicare claims to record the placement of the vasoseal and for other payers as directed.

 

References:
Centers for Medicare and Medicaid Services at www.cms.gov
ICD-10 Procedure Coding System (ICD-10-PCS) 2016 Tables and Index, downloaded from http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html on 6/30/2015.
CPT® Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


PAYMENT FOR PERIPHERAL INTERVENTIONS

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.

Medicare Hospital Inpatient Payment

Medicare hospital inpatient payment is effective for the fiscal year (FY) (October 1 through September 30)

MS-DRG FY 2017 National Base Payment1
252

Other vascular procedures with major complication or comorbidity

$19,754

253

Other vascular procedures with complication or comorbidity

$15,768

254

Other vascular procedures without complication or comorbidity/major complication or comorbidity

$10,593

Medicare Hospital Outpatient Payment

Medicare hospital Outpatient payment is effective for the calendar year (CY) (January 1 through December 31)

APC CY 2016 National Payment2
5191

Level I Endovascular Procedures

$4,592

5192

Level II Endovascular Procedures

$9,542

5193

Level III Endovascular Procedures

$14,612

Medicare Physician Payment

Medicare Physician payment is effective for the calendar year (CY) (January 1 through December 31).

Peripheral Angioplasty

CPT® Codes CY 2016
National
Payment*3
2016 Total Facility RVUs 2016 Total Non-Facility RVUs
35471 Transluminal balloon angioplasty, percutaneous; Renal or visceral artery $549 15.33 72.67
35475 Transluminal balloon angioplasty, percutaneous; Brachiocephalic trunk or branches, each vessel $349 9.74 44.26
35476 Transluminal balloon angioplasty, percutaneous; Venous $282 7.87 40.57
37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty $439 12.22 89.86
37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) $197 5.51 25.24
37224 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal angioplasty $482 13.44 109.00
37228 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal angioplasty $589 16.43 154.86
37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) $214 5.97 34.51

Peripheral Stent Placement

CPT® Codes CY 2016 National Base Payment*3 2016 Total Facility RVUs 2016 Total Non-Facility RVUs
37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within same vessel, when performed $538 15.01 132.42
37223 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within same vessel, when performed (List separately in addition to code for primary procedure) $226 6.32 73.64
37226 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed $566 15.80 257.45
37230 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed $751 20.95 236.02
37234 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) $300 8.38 110.26
37236 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angiooplasty within the same vessel, when performed; initial artery $477 13.30 116.96
37237 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure) $225 6.27 69.92
37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein  $330 9.21 119.20
37239 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure)  $157 4.39 57.70

Bundled codes include all work done on treatment side (catheter placement, angioplasty, angiography and stent placement).

*National Facility Rate

 

1 FY2017 Inpatient Prospective Payment System Final Rule CMS-1655-F; CMS-1664-F; CMS-1632-F2.
2 CY2016 Outpatient Prospective Payment System Final Rule; 42 CFR Parts 405, 410, 412, 413, 416, and 419 [CMS-1633-FC]; Accessed October 30, 2015.
3 CY2016 Physician Fee Schedule, Final Rule; Centers for Medicare & Medicaid Services 42 CFR Parts 405, 410, 411, 414, 425, and 495 [CMS-1631-FC]. Accessed November 16, 2015.

References:
Centers for Medicare and Medicaid Services at www.cms.gov 
CPT®Copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


PERIPHERAL INTERVENTIONS COVERAGE

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.

Medicare Coverage

Medicare coverage of Percutaneous Transluminal Angioplasty (PTA) falls under a National Coverage Determination (NCD). Please click here to link to the NCD: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=201&ver=9. Coverage for peripheral vessel stenting may vary by Medicare Contractor. Abbott recommends that providers verify Medicare coverage of peripheral procedures prior to date of service.

Commercial Coverage

Commercial Coverage of peripheral interventions may vary.

For reimbursement purposes, Abbott Vascular recommends that providers verify insurance coverage prior to performing a procedure.

STRUCTURAL HEART PROCEDURES

Here you’ll find the information you need related to coding, coverage and reimbursement for transcatheter mitral valve repair procedures (TMVR). Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.


STRUCTURAL HEART PROCEDURE CODES

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies. If you are a participating site in the COAPT study and have coding questions, please contact the Reimbursement Hotline.

ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes are effective as of October 1, 2015. If you have any questions related to the former ICD-9 or current ICD-10 coding for procedures involving Abbott devices, please contact the Reimbursement Hotline at 800 354 9997 or Questions@AskAbbottVascular.com

Common ICD-10-CM Diagnosis Codes

ICD-10-CM diagnosis codes are used by hospitals to document the clinical condition of the patient undergoing the procedure. Below are the ICD-10-CM codes currently included in the NCD for TMVR. It is the responsibility of the hospital and physician to determine the appropriate diagnosis code(s) for each patient.

ICD-10-CM Diagnosis Codes
I34.0 Nonrheumatic mitral (valve) insufficiency
I34.1 Nonrheumatic mitral valve prolapse2
Z00.6* Encounter for exam for normal comparison and control in clinical research program

*For commercial cases enrolled in the TVT Registry, this secondary diagnosis code is required per MLN Matters® Number MM9002.

ICD-10-PCS Procedure Codes

Hospital Inpatient ICD-10-PCS procedure codes to describe TMVR are detailed below. Diagnostic cardiac catheterization may also be coded when it is performed for specific evaluation beyond the approach to the procedure. If the cardiac catheterization is part of the approach for the procedure, it may not be coded separately.1 Providers should consult with their payer regarding appropriate coding policies for the procedures.

ICD-10-PCS Procedure Code - TMVR
0      Medical and Surgical
2      Heart and Great Vessels
U     Supplement – Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part
Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7
G Mitral Valve 3 Percutaneous J Synthetic Substitute Z No Qualifier
ICD-10-PCS Procedure Code - TEE
B      Imaging
2      Heart
4      Ultrasonography – Real time display of images of anatomy or flow information developed from the capture of reflected and attenuated high frequency
Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7
5 Heart, Left Z None Z None 4 Transesophageal

For other concomitant conditions, other TEE codes may apply.

Physician Codes

CPT® codes to describe the work performed for TMVR, fluoroscopy and transesophageal echocardiography (TEE) are also provided below.

CPT Code Descriptor 
TMVR Procedure with Implant
33418 Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; initial prosthesis
33419 Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; additional prosthesis (es) during same session (List separately in addition to code for primary procedure). (Use 33418 in conjunction with 33419)
Angiography, radiological supervision, and interpretation performed to guide TMVR (e.g., guiding device placement and documenting completion of the intervention) are included in these codes. Do not report diagnostic right and left heart catheterization procedure codes (93451, 93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530, 93531, 93532, 93533) with 33418 or 33419 when done intrinsic to the valve repair procedure.
Transesophageal Echocardiography (TEE) (for intra-procedural monitoring)
93355 Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (eg,TAVR, transcathether pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure) (peri-and intra-procedural), real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D     
Required modifiers for commercial cases
Q0* Investigational clinical service provided in a clinical research study that is in an approved clinical research study.

*For cases enrolled in the TVT Registry, this modifier is required per MLN Matters® Number MM9002

Other Coding Guidance

For commercial cases enrolled in the TVT Registry, include Condition Code 30 and the eight-digit clinical trial number for the mitral module of the TVT Registry, 02245763.  For additional information on coding for TMVR cases, refer to MLN Matters® Number MM9002

 

1 AHA Coding Clinic, Third Quarter, 2004, page 10
2 Per CMS Transmittal 1630, released February 26, 2016

CMS MLN Matters MM9002 Transcatheter Mitral Valve Repair (TMVR)-National Coverage Determination (NCD)
ICD-10-CM Tabular List of Diseases and Injuries, downloaded from http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html on 6/30/2015.
ICD-10 Procedure Coding System (ICD-10-PCS)
2016 Tables and Index, downloaded from http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html on 6/30/2015.
CPT® Copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


STRUCTURAL HEART PROCEDURE PAYMENTS

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.

Medicare Hospital Inpatient Payment

Medicare hospital inpatient payment is effective for the fiscal year (FY) (October 1 through September 30) 

MS-DRG

Descriptor

FY 2017 Medicare National Average Payment Rate1

228 Other Cardiothoracic Procedures with major complication or comorbidity $42,262
229 Other Cardiothoracic Procedures without major complication or comorbidity $28,302 

Note that actual hospital MS-DRG payment will vary based on adjustments for factors including geographic differences,  teaching status, and disproportionate share of indigent patients.

Currently, the MitraClip System is the only FDA approved TMVR device commercially available in the US. 

Medicare Physician Payment

Medicare Physician payment is effective for the calendar year (CY) (January 1 through December 31).

New Category 1 CPT® codes for transcatheter mitral valve repair and interventional transesophageal echocardiography were created by the AMA and are payable as of January 1, 2015.

CPT® CY 2016
National
Payment*2
2016 Total Facility RVUs
TMVR Procedure with Implant
33418 Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; initial prosthesis $1,874 52.30
33419 Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure). (Use 33418 in conjunction with 33419) $441 12.31
Angiography, radiological supervision, and interpretation performed to guide TMVR (eg, guiding device placement and documenting completion of the intervention) are included in these codes. Do not report diagnostic right and left heart catheterization procedure codes (93451, 93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530, 93531, 93532, 93533) with 33418 or 33419 when done intrinsic to the valve repair procedure.
 Transesophageal Echocardiography (TEE) (for intra-procedural monitoring)
93355 Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (eg,TAVR, transcathether pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure) (peri-and intra-procedural), real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D $231 6.44

 

*National Facility Rate

1 FY2017 Inpatient Prospective Payment System Final Rule CMS-1655-F; CMS-1664-F; CMS-1632-F2.
2 CY2016 Physician Fee Schedule, Final Rule; Centers for Medicare & Medicaid Services 42 CFR Parts 405, 410, 411, 414, 425, and 495 [CMS-1631-FC].  Accessed November 16, 2015.

References
Centers for Medicare and Medicaid Services at www.cms.gov
CPT® Copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


STRUCTURAL HEART PROCEDURES COVERAGE

Providers should consult with their payers regarding appropriate documentation, medical necessity and coding information consistent with individual payer requirements and policies.  

Medicare Coverage

On August 7, 2014 the Centers for Medicare and Medicaid Services (CMS) finalized a national coverage determination (NCD) for transcatheter mitral valve repair (TMVR).1 The NCD for TMVR extends coverage to U.S. Medicare beneficiaries based on the CMS Coverage with Evidence Development (CED) framework that is designed to provide more timely access to breakthrough technologies. All TMVR cases will be submitted to the national Transcatheter Valve Therapy (TVT) registry to track real-world outcomes. The NCD is effective for dates of services beginning on August 7, 2014.  

Please click here to access the NCD

Please click here to access the NCD implementation instructions

Private Payer Coverage

Commercial insurance coverage for TMVR varies. Providers should consult with their payer on coverage requirements and criteria prior to performing any procedure.

1 National Coverage Determination for Transcatheter Mitral Valve Repair 20.33

 

Disclaimer: The information provided in this document was obtained from third-party sources and is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, policies, and payment amounts. All content is informational only, general in nature, and does not cover all situations or all payers’ rules and policies. It is the responsibility of the hospital or physician to determine appropriate coding for a particular patient and/or procedure. Any claim should be coded appropriately and supported with adequate documentation in the medical record. A determination of medical necessity is a prerequisite that Abbott assumes will have been made prior to assigning codes or requesting payments. Any codes provided are examples of codes that specify some procedures or which are otherwise supported by prevailing coding practices. They are not necessarily correct coding for any specific procedure using Abbott products.

Hospitals and physicians should consult with appropriate payers, including Medicare Administrative Contractors, for specific information on proper coding, billing, and payment levels for healthcare procedures. Abbott makes no express or implied warranty or guarantee that (i) the list of codes and narratives in this document is complete or error-free, (ii) the use of this information will prevent difference of opinions or disputes with payers, (iii) these codes will be covered [or (iv) the provider will receive the reimbursement amounts set forth herein]. Reimbursement policies can vary considerably from one region to another and may change over time.

The FDA-approved/cleared labeling for all products may not be consistent with all uses described herein. This web page is in no way intended to promote the off-label use of medical devices. The content is not intended to instruct hospitals and/or physicians on how to use medical devices or bill for healthcare procedures. 

Last Updated: November 2016

AP2943253-WBU Rev. A

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